Analysis Grounding Sequence When the course alteration was made and full port rudder was applied, Johnson Point was abeam and some 60m off the port side of the Algontario. The after half of the ship's length was still in the port side lane of the channel, while the forward end was in the wider and clearer water ahead of Johnson Point. Consequently, while the port bow was free of bank suction effect, the after end of the vessel was still under its influence until the stern also cleared Johnson Point. The effect of bank suction at the after end was to draw the stern of the vessel to port and nearer to the channel side, while the forces of the hard-over rudder tended to move the stern to starboard. The opposed actions of the bank suction and rudder forces continued until the stern finally cleared Johnson Point, and so retarded the initiation of the vessel's turn. The delay in the initiation of the change of course resulted in the vessel overshooting the intended turning point, and in her continuing for some time diagonally across the bend in the channel before responding to the rudder action. The channel depth at, and upstream of, Johnson Point is relatively shallow, and the vessel speed and draughts were such as to cause the hull to squat approximately 0.7m. The squat reduced the actual UKC at the stern to some 0.33m and increased the wave-making resistance at the forward end of the vessel. When the vessel was completely clear of Johnson Point and proceeding diagonally across the channel, the action of the 2-knot current was acting on the port side of the hull and tended to set the bow to starboard. This action in conjunction with the concurrent effects of squat and wave-making resistance combined to detrimentally affect the vessel's handling characteristics and slowed the rate of change of course expected from the hard-over rudder. The overshoot of the intended turning point and the slower-than-anticipated rate of change of course caused the vessel to ground on the outer edge of the bend in the channel and incur extensive bottom shell damage on her starboard side. Bridge Navigation Team Like most lakers in the Great Lakes/St. Lawrence River System between St. Lambert lock and Lake Superior, the Algontario was exempt from having to take a pilot. The bridge navigation team was therefore composed of the master, an OOW, and a quartermaster at the helm. In the St. Marys River, it was a regular practice for the master to con the ship. An ECDIS was available to assist the navigation team in the narrow waterway. A passage plan had been loaded on the ECDIS for the Lake Huron passage. No detailed passage plan had been prepared for the river. The vessel was ballasted in the tanks known to be watertight and not subject to water migration but these were not sufficient in number to significantly reduce her trim by the stern. The OOW's duties included monitoring the helmsman and the master's pilotage commands as the passage proceeded. The officer also recorded the vessel's progress by noting the time when passing certain points along the river. The OOW did not provide any significant inputs to ensure an effective river passage, nor did the master ask for his input. Johnson Point is a winter calling-in point. Normally, vessels make their report further south. The master made the report himself. He also used the spotlight to locate buoy Q22 in the darkness. These actions may have distracted the master from other navigation duties. The master did not ask the mate to assist him with the calling-in point report or to spot buoy Q22 at a critical alteration of course near Johnson Point. Vessel Draught vs. Channel Depth The post-casualty sounding survey conducted by the U.S. Army Corps of Engineers confirmed normal project depths in the 8.45m, 8.2m, and 6.40m deep channels. With a static after draught of 7.8m (and trimmed by the stern approximately 1.20m), the Algontario was too deep to enter the shallow 6.4m deep section of the Middle Neebish Channel (Course8). Consequently, safe navigation of the vessel was restricted to the deeper lanes of the channel. The Turn at Johnson Point There is a speed limit of 7.8knots in Neebish channel. The two deep water channels are marked by the Sailor's Encampment, Rains Wharf, and Point of Woods ranges. From Course9 to Course8, vessels must make a 63 alteration of course in a channel that is 91m (300feet) wide (on Course9) and 182m (600feet) wide (on Course8). Vessels approaching Johnson Point need to proceed at a reduced speed to minimize shallow water or squat effect while negotiating the turn. Local pilots report using a speed of 7knots to control the turn at Johnson Point. It was also reported that some lake masters have used a two-leg approach to make the turn. First, by staying close to the middle of Course9, then by steering on buoy Q22 for a short period before completing the turn and steadying the ship on Point of Woods range. The master on the Algontario used the single helm order Port or Come to Port to start the turn. It was reported that he always meant Hard to Port at Johnson Point and there was no confusion as to the meaning of his helm order. The helmsman put the helm 35degrees to port without delay. The vessel started the turn at a speed of 7.1knots; more power was then applied to the propeller to increase the turning rate. There is conflicting information as to when the order to turn was given. Information retrieved from the ECDIS suggests that there is a discrepancy between the location where the order Come to Port was reportedly given and the position of the vessel when the bow started to swing to port. In fact, two thirds of the ship's length had passed Johnson Point light when the first change of heading was recorded (seeAppendixA). The trace on the ECDIS shows that the vessel stayed in the deep water channel all the way on Course9 with a minor adjustment for set near buoy Q18 at 0836. The bow of the vessel was well past Johnson Point light when it started to swing to port at 0840. A current of approximately 2knots acting on the port side would have reduced the rate of turn, causing the turning circle to be larger than anticipated. Accidents in Neebish Channel The split channel leading to Johnson Point has been the site of other groundings. The TSB has recent records of a similar shipping accident, involving a vessel striking the shallow depth side of a split channel. In April 1999, the laker JeanParisien contacted bottom below Johnson Point. The vessel damaged its hull plating while navigating in the 21-foot-deep section of the Neebish Channel (Course 9). On 6April2000, the JamesR.Baker, a downbound 1,004-foot-long US bulk carrier contacted the river bottom at the upper end of the West Neebish Channel on the US side of the river, sustained damage, and flooded the forward starboard ballast tank. While approaching Johnson Point, the helm orders were not given in sufficient time to successfully execute the 63 course alteration to port in a 180m wide channel. The squat effect reduced the UKC of the vessel from 1.04m to 0.33m, which, in conjunction with bank suction and the vessel's speed of 7.2knots, would have retarded her initial rate of turn. The vessel's speed of approach to round Johnson Point was not sufficiently reduced to take into account the lower-than-usual water level in the area. The master and the mate had both received BRM training but the implementation of BRM principles was not optimized. The less than optimal communication and division of reponsibilities between the master and the bridge team resulted in the former taking on an additional workload at a critical point in the vessel's transit.Findings as to Causes and Contributing Factors While approaching Johnson Point, the helm orders were not given in sufficient time to successfully execute the 63 course alteration to port in a 180m wide channel. The squat effect reduced the UKC of the vessel from 1.04m to 0.33m, which, in conjunction with bank suction and the vessel's speed of 7.2knots, would have retarded her initial rate of turn. The vessel's speed of approach to round Johnson Point was not sufficiently reduced to take into account the lower-than-usual water level in the area. The master and the mate had both received BRM training but the implementation of BRM principles was not optimized. The less than optimal communication and division of reponsibilities between the master and the bridge team resulted in the former taking on an additional workload at a critical point in the vessel's transit. Although the depth of the water was at a level lower than had been experienced in years, it was consistent with the U.S. Army Corps of Engineers' parameters for the channel. The grounding occurred at a time when the alertness of the bridge team would have been at its lowest.Findings Related to Risk Although the depth of the water was at a level lower than had been experienced in years, it was consistent with the U.S. Army Corps of Engineers' parameters for the channel. The grounding occurred at a time when the alertness of the bridge team would have been at its lowest. Safety Action Action Taken On April 8 the U.S. Army Corps of Engineers performed a sweep survey of the federal navigation channel at the Middle Neebish Channel (upbound) Course8, at the location of the grounding, and later issued a Notice to Navigation Interests L99-28 dated 9April1999 indicating that the 21ft. and 28ft. project depths were available as advertised. Algoma Central Marine's Safety Management System (ISM certified) contains a Safe Underkeel Clearance section outlining to navigating officers the requirement to maintain safe underkeel clearance throughout a voyage. The system was in place before the grounding. Subsequent to the incident, Algoma Central Marine issued a memorandum to remind masters of the prevailing lower water levels in the area and of the effects of shallow water vessel manoeuverability.